We present an extremely rare case of amyloid A (AA) deposition in the gallbladder and review the literature on similar cases. The patient was a 76-year-old man who had been diagnosed with mild bronchiectasis three years previously, who was admitted to the hospital with right upper quadrant pain and fever. Computed tomography revealed swelling and wall thickening of the gallbladder with a small gallstone. The patient was diagnosed with acute cholecystitis and cholelithiasis and underwent open cholecystectomy. A postoperative histological examination revealed extensive AA deposition in the gallbladder wall. Thus, the definitive diagnosis was acute cholecystitis with AA amyloidosis.

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.

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